The Reality of Optometry Internship Placements in Nigeria

When I was in school I didn’t think much about internship, I expected it to be a time for learning while making some cool cash. Every one of us, back then had different expectations of the one year assigned for it but the generally held idea was that, it was going to be a time to garner experience while putting away that cool cash.

‘Government clinics do not absorb enough interns and most interns have no choice but to settle for private clinics where there is little or no remuneration’, this was the opinion an optometry graduate I talked to in the course of writing this article. When assessing available internship positions, government owned clinics offer higher pay and better hours and this holds greater appeal for new graduates. Considering the number of slots available vis-a-vis the turnout from optometric schools in the country yearly, it would be discovered that only a small percentage of graduates have an honest chance of getting into government establishments. The rest would have to make do with privately-owned clinics around the country.

We all want these government clinics, making the competition fierce. Besides, the general belief is that most of these spots cannot be gotten by merit alone; it would require knowing someone in the system (having long legs). A case of double trouble for those without ‘long legs’.

At present, there are five schools offering the OD (Doctor of optometry) in Nigeria. Every year these schools graduate a number of students. Using the University of Benin as an example, about 50 to 70 graduates are inducted each year with the number of admissions increasing every year. With 22 federal medical centres, several teaching hospitals, general hospitals and other healthcare facilities; there ought to be enough internship slots provided a sizeable number of these facilities take interns, sadly this this is not the case. The unrest in the northern part of the country further reduces the number of available positions. However, it must be stated that these places can absorb an average of 4 interns without hurting their budgets and every licensed optometrist with 5 years post NYSC experience is allowed to train up to six interns.

In my opinion, the number of new admissions in all schools of optometry should be tailored such that a large percentage of would-be graduates should be able to find themselves internship placement with the government. This by itself would curb the need for all the long leg bull shit. It would also help if all government secondary and tertiary facilities were to have optometry clinics. The general feeling is that responsibility for this lies with the Nigerian Optometric Association (NOA) and the Optometrists’ and Dispensing Opticians’ Registration Board of Nigeria. They should push for more policies to be created and implemented to achieve these and the internship programme should be restructured with a view to standardizing the learning experience.  The standardized minimum amount payable to interns should be better canvassed.

However, laudable programmes such as the Family of Optometry Mentors (FOM) instituted by the state chapters of NOA in Abuja and more recently Lagos deserve commendation. These are the kind changes I believe most interns would like to see, it can still get better!

What Medication Error means for the Nigerian Optometrist

Introduction

Medication errors are errors in prescribing, dispensing and administering pharmaceutical agents 1. There has been widespread reports of medication errors and the harm it poses to body tissues 2. These errors could arise from the clinician, the dispenser or the drug user.

The Nigerian Situation

I have experienced, heard and witnessed dispensing faults. One recent case was on prescribing artificial tears, the patient presented a topical antifungal drug (Fluconazole gutta) purchased from a local chemist. 

Relevant research papers have shown that the Nigerian health care system has had a share in the battle of medication errors 3, 4, 5. This has been attributed on the part of health care workers in Nigeria to not enough age consideration in dosing, omission of dosage duration in prescribing, wrong dosage duration, over dosing, under dosing and seemingly unsatisfactory labelling of drugs by manufacturers

Where does the Nigerian Optometrist come in?

The training curriculum for optometrists in Nigeria allows for competency up to level four of the Global Competency Model for Optometry (Ocular Therapeutics). This puts the optometrists in the battle against medication errors as they strive to provide quality eye care services to the populace. Even though it is accepted by the ophthalmic world that ophthalmic topical drugs have little adverse effects compared to systemically administered drugs, this does not exclude the optometrist from this battle in any way. Leaving aside the fact that optometrists also prescribe systemic drugs in Nigeria, misuse of some topical ophthalmic preparations can cause adverse effects on the ocular tissues and adnexa. We of course shouldn't forget documentations of topical steroid induced glaucoma and cataract or fungal infections of the conjunctiva and cornea due to abuse of topical antibiotics.

How do we optometrists tackle this?

These errors comes from three main sources, the prescribing optometrist, the dispenser and the patient. 

On the part of the optometrist, he/she must be conversant with the pharmacokinetics and pharmacodynamics of the drug to be prescribed taking into special consideration children, nursing mothers and the aged. To reduce the errors made by the optometrist, one can employ the use of online tools like drugs.com and cataloguing drug dosage information in readily available hard copy prescription charts in clinics. 

Medication errors from the dispenser can be prevented by having a pharmacy with monitored dugs in the same optometry clinic facility that prescriptions are made, by a feedback system allows for the patient to present the drug purchased outside the clinical facility to the prescribing optometrist before administration. 

Medication errors in administration can be tackled by proper education of the patient by the optometrist on the use the use of the drug with the incorporation of the dos and donts method. 

I should also add that the optometry schools must take pharmacology courses much more seriously with an approach that enables students not only know the pharmacological details of ophthalmic drugs but also to be conversant with the ophthalmic drugs in the Nigerian market. In our Continuing Education Programmes, the newer ODs who seem more prone to such errors should be specially educated.

It is believed that through considering and implementing  these recommendations, we can serve the vision of the populace better and create a better name for the profession in Nigeria. You can add more recommendations in the comments section.

References 

1. Medical Dictionary 2015, Medication Errors, viewed 9 March 2015.

http://medical-dictionary.thefreedictionary.com/medication+error

2. Velo GP,  Minuz P 2009, Medication Errors: prescribing faults and prescription errors, British Journal of Clinical Pharmacology, vol 67, no 6, pp 624-628, viewed 9 March 2015. 

http://www.ncbi.nlm.nih.gov/pubmed/19594530

3. Oshikoya KA, Ojo OI  2007, Medication errors in paediatric outpatient prescriptions of a teaching hospital in Nigeria, Nig Q J Hosp Med, vol 17, no 2, pp. 74-78, viewed 9 March 2015. 

http://www.ncbi.nlm.nih.gov/pubmed/18318097

4. Nwasor EO, Sule ST, Mshelia DB 2014, Audit of medication errors by anesthetists in North Western Nigeria,  Niger J Clin Pract, vol 17, no 2, pp 226-31, doi:10.4103/1119-3077.127563.

http://www.ncbi.nlm.nih.gov/pubmed/24553036

5. Oyedunni S. Arulogun*, Simon K. Oluwole and Musibau A. Titiloye 2011, Prescription Errors Prevalent in Four Units of a University Teaching Hospital in Nigeria, Journal of Public Health and Epidemiology, vol 3, no 11, pp 513-519. viewed 9 March 2015. 

http://www.academicjournals.org/JPHE

Hyperopia

Introduction

Hyperopia denotes a visual condition of behind foveal focusing of distant images the optical system of the eye when accommodation is relaxed. Research reports that hyperopes outnumber myopes in the population.

Presentation
The presentation of hyperopia depends on age and magnitude. Younger low hyperopes typically present with good visual acuity and near vision adequacy. This is attributed to the efficient accommodation reserves in the young. This cannot be said of the moderate and higher young hyperopes. The moderate young hyperopes may present with eye strains (which is sometimes described as pain) on near work even with good visual acuities and near vision adequacy. High young hyperopes present with subnormal visual acuities and near vision inadequacies. With high young hyperopes, the accommodative reserves are inefficient to cope with the high magnitude of hyperopic defocus.
The older hyperopes (35 and above) present may present with reduced visual acuities and near vision inadequacy.

Manifest or Latent? Manifest hyperopia is that hyperopia which is revealed on subjective refraction whether visual acuities are normal or subnormal. There are two types of manifest hyperopia; Facultative and Non-facultative hyperopia. The facultative form which can be compensated by accommodation and presents in the younger population due to the efficient accommodative reserves. Facultative hyperopia presents with normal visual acuities due to accommodative compensation. For the older, the non-facultative form which cannot be corrected by accommodation presents often because of the lowered accommodative reserves. In the non-facultative form, visual acuities are also reduced due to decompensation by accommodation.

Latent hyperopia is due to constant contraction of the ciliary muscles of accommodation (spasm). This commonly presents in younger hyperopes. It is never exposed on subjective refraction except through induced cycloplegia with topical cycloplegic drugs and to some extent, with fogging retinoscopy (the eye not scoped is first fogged with plus lenses till an against motion is seen in one meridian before scoping the opposite eye).

The confusion between latent and facultative hyperopia
It seems easy to confuse both. Reason been that they present in the young and present similarly with good visual acuities and sometimes, complaints of strains on near work. If on adding plus spheres, good visual acuities remain up till a point of first sustained blur, then the hyperopia up to the point of first sustained blur has previously been corrected by accommodation and is the measure of facultative hyperopia. The magnitude of the facultative hyperopia is the power of the plus lens that causes the first sustained blur. Latent hyperopia is never exposed as such.

Forms of hyperopia are not mutually exclusive
This means that latent and manifest hyperopia do occur at together. The same holds for facultative and non-facultative hyperopia.

Reference
American Optometric Association 2008, Care of the patient with hyperopia, viewed 2 March 2015, <https://www.google.com.ng/url?sa=t&source=web&rct=j&ei=MU37VL_HCYbP7Qa7joDoBQ&url=http://www.aoa.org/documents/optometrists/CPG-16.pdf&ved=0CB0QFjAA&usg=AFQjCNHjTbxzaXld8-AkJ_owHlCDthE3EQ&sig2=9MaAbI3miBtcmIJ0euquag>